A client diagnosed with end-stage kidney injury receives continuous ambulatory peritoneal dialysis (CAPD). The nurse observes that the dialysate drainage fluid is cloudy. What is the priority intervention?
Administer a bolus of IV normal saline as ordered
Flush the peritoneal catheter with normal saline
Assess the client for signs of infection
Continue to monitor the color of the dialysate
The Correct Answer is C
Choice A reason: Administering IV normal saline addresses fluid volume deficits, not cloudy dialysate, which suggests peritonitis in CAPD. Saline does not treat infection or clarify drainage. Without addressing the potential infection, complications like sepsis or peritoneal membrane damage may occur, making this intervention irrelevant to the finding.
Choice B reason: Flushing the peritoneal catheter with saline risks introducing bacteria or dislodging clots, worsening potential infection. Cloudy dialysate indicates peritonitis, requiring assessment and likely antibiotics, not flushing. This action could compromise the catheter’s integrity and is not a standard intervention for suspected peritonitis in CAPD.
Choice C reason: Cloudy dialysate is a hallmark of peritonitis in CAPD, caused by bacterial infection. Assessing for fever, abdominal pain, or rebound tenderness confirms infection, enabling prompt antibiotic treatment. Early intervention prevents sepsis or peritoneal membrane scarring, which could necessitate dialysis modality change, making this the priority action.
Choice D reason: Continuing to monitor without assessing for infection delays treatment of potential peritonitis, a serious CAPD complication. Cloudy dialysate requires immediate evaluation, as untreated infection can lead to sepsis, peritoneal damage, or death. Passive monitoring risks patient safety, making this an inadequate response to a critical finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Neighborhood watch programs enhance community safety but do not directly address mental health needs. They lack therapeutic components to manage symptoms or prevent decompensation, which are critical for preventing readmission in clients with mental health disorders, making this factor less relevant to sustained community stability.
Choice B reason: Taking meals at a food bank addresses nutritional needs but does not directly support mental health stability. While nutrition is important, it does not provide the therapeutic interventions or coping strategies needed to manage mental health disorders and prevent relapse or hospital readmission.
Choice C reason: Participation in treatment, such as therapy or medication adherence, directly addresses mental health symptoms, improving coping skills and emotional regulation. Consistent treatment reduces relapse risk, enhances stability, and supports community integration, making it the most effective factor for preventing readmission in clients with mental health disorders.
Choice D reason: A safe living environment reduces stress and safety risks but is secondary to active treatment. Without ongoing therapy or medication, environmental safety alone cannot manage symptoms or prevent decompensation, making it less critical than treatment participation for maintaining community stability and avoiding readmission.
Correct Answer is A
Explanation
Choice A reason: Silence allows the client to process trauma at their own pace, creating a safe, non-pressurized environment. Fearful clients may need time to feel secure before speaking. This technique fosters trust, encourages emotional expression, and is particularly effective in trauma, where verbalization can be challenging due to psychological distress.
Choice B reason: Giving information provides facts but may overwhelm a fearful client, who may not be ready to process details post-trauma. This technique is less effective for engagement, as it does not address emotional barriers or encourage self-expression, which are critical for therapeutic interaction in trauma recovery.
Choice C reason: Focusing directs the conversation to specific topics, which can feel intrusive for a traumatized client. It assumes readiness to discuss, potentially increasing anxiety or withdrawal. This technique is less effective than silence, which allows the client to initiate dialogue when emotionally prepared, fostering trust.
Choice D reason: Broad opening encourages the client to choose topics but may be too vague for a fearful, traumatized client, who may feel overwhelmed by the lack of structure. Silence is more effective, as it provides space for emotional processing without pressuring the client to verbalize prematurely.
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